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10 Myths of Population Health and Clinical Transformation

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March 01, 2016

It is a confusing time in United States healthcare. Healthcare organizations are faced with the new reality of value-based care and are identifying the necessary steps for success in an evolving healthcareenvironment. For many, this transformation is difficult, and fear of this change may hinder progress. However, at present, a lack of true understanding of the care processes, tools, and consequences of this transformative shift persists in the healthcare community, and with the public at large. The delivery and consumption of care is rapidly changing for both provider and patient, and not everyone is on the same page. Below are ten myths associated with clinical transformation and its ability to position an organization for success in a value-based world, along with the realities with which providers and organizations must face.

Myth #1:The best care (or better care) is provided in hospitals.

Reality: For many years, the United States healthcare system has been very hospital-centric. Patients who were sick were directed to go to the Emergency Room or the hospital to get better, and physicians were paid handsomely for services provided in the hospital setting. This cycle has engrained within Americans (and within many physicians) that the hospital is the setting for receiving the highest quality of care. Patients will often even ask to be admitted to the hospital because they believe superior care will be provided there. Today, the healthcare system has begun to shift to improve and increase the suite of outpatient healthcare services to include ambulatory surgery centers, urgent care centers, retail clinics, even home-based care. The hospital is no longer the only place to go to receive care and, in fact, the best interventions will keep patients safely in their homes and out of the hospital altogether.

Reality: While value-based payments are a driver for clinical transformation, organizations should move at the pace of their market (and their own capabilities). Each market across the county differs in its pace in the shift from a volume to value-based environment. Organizations who are maintaining success in a primarily fee-for-service environment may not be ready for an immediate switch to value-based payments. Instead, these organizations should begin undertaking efforts to prepare for an eventual change to value-based contracting through improved medical management efforts and regular analysis on clinical outcomes and cost of care. This transition for some has had to be rapid, given the speed with which the market had adopted value-based payments. However, for many others who are not yet positioned for success in a value-based market, this transition should be gradual as the organization begins to develop the necessary capabilities; in a volume-based environment, these changes can still have positive outcomes through a focus on treating patients in appropriate care settings, thereby increasing capacity and access. Therefore, the focus for all organizations should be developing and implementing the clinical care model that is in sync with its payer contracting strategy.

Reality: As healthcare organizations begin to explore the clinical transformation needed to achieve clinical integration, the number one barrier frequently identified is the lack of interoperability among the health IT systems. Often, organizations may decide a complete IT overhaul is necessary (very costly) or that clinical integration is simply not possible and withdraw from the effort. However, highly integrated IT systems do not magically result in clinical integration. IT systems lack the clinical judgment that is necessary to provide high-quality, patient-centric care. IT systems cannot identify population health objectives and goals and design interdisciplinary medical management programs that aim to meet population health goals. It is the aligned vision for improving health outcomes among all care team members that results in clinical integration; IT systems can simply enable this type of care through real-time alerts, evidence-based clinical pathways, and historical and predictive trending of clinical data and notes. Interoperability should be viewed as a means, not as a deal breaker in its absence.

Reality: Advances in technology have provided innumerous innovations to the majority of industries and society in general. While healthcare has been an undeniable benefactor, it is widely assumed that because electronic tools have made the public’s lives significantly easier, healthcare providers have experienced the same benefits and welcome all advancements. Healthcare IT, including EMRs, can provide the care team (e.g., the physician, medical assistant, nurse, social worker, or other care coordinator), with a wealth of knowledge about each patient. Tools exist that track and trend lab results, maintain and update a singular care plan, and provide point-of-care alerts to close gaps in care. Many organizations rely heavily on the information provided through these tools to provide patient-centered, high-quality care. However, it is not the information contained within these tools that has enhanced patient care; instead, it is the care processes and workflows that have been developed to ensure this information is meaningful and utilized that has enhanced care. Without clear care protocols or actionable reports, physicians can be frustrated by the vast amount of information presented to them and the myriad of tasks they must complete within multiple IT systems. Too much data contained in a myriad of health IT systems can actually result in less coordinated care between physicians and across care settings. It is the integration of this information, in a succinct form, into clearly defined care processes that enables the delivery of high-quality patient care and allows the technology to ease the burden on the provider, rather than add to it.

Reality: Additional capital to support informatics and staffing are a luxury and can improve efficiency and effectiveness of care management initiatives, but they are in no way a necessity for population health management. Population health management begins with a cultural transformation within the organization that is centered on a dedication to providing high-quality, patient-centric care. A clinical transformation subsequently occurs that leads to the development and establishment of refined clinical pathways and processes and often the redeployment of staff. IT tools can assist with these processes, but they should not drive the clinical transformation that needs to occur within the care teams. Similarly, the role of support staff (e.g., care managers, social workers, health coaches) does not actually increase; instead roles are assessed and redefined, as necessary, to ensure staff resources are deployed in a manner that is targeted to meets the needs of the population and the associated intervention. Too often organizations making this transition attempt to run before they can walk.

Myth #6: Clinical integration results in mass layoffs of staff.

Reality: The Triple Aim® consists of three components: improved health outcomes, improved patient experience, and reduced overall cost of care. While it is imperative that all three of these tenets are taken into consideration for successful clinical transformation, providers frequently focus on the latter and associate it with cost and workforce reductions. Often, organizations are not over-staffed for population health management; instead, staff members are simply not working to the top of their license and are not always providing care to the right cohort of patients, at the right point in time, with the right care interventions to meet the patient’s needs. A reduction in staff will only increase the volume strain all staff is already experiencing. Instead, an assessment and redesign of clinical protocols should inform the medical management staffing. A re-deployment of staff may be necessary to ensure staffing levels are congruent with the acuity of the patient population, and additional training may become necessary to ensure all staff members are able to perform effectively and efficiently in new roles. In many cases, rightsizing can be replaced by adhering to clinical protocols and reallocating existing workforces.

Myth #7: Buying services that span the continuum is the only way to achieve clinical integration.

Reality: The desire to purchase services that span the continuum stems from a need to be able to share clinical information, conduct warm handoffs between care settings, and keep healthcare costs and revenue under a single umbrella. However, just because an organization may own these services does not mean that these services are the highest quality, nor even utilized by other providers in the continuum. What is most important when developing a clinical integration model is the provision of high-quality, patient-centric care across the continuum. Services do not need to be owned to meet this obligation. Organizations should be looking, instead, to develop formal relationships with the most high-quality and value-based healthcare service providers. Referrers should have access to cost and quality metrics for all partner organizations and should utilize these results to drive care to the most appropriate providers. Preferred networks should be developed to enable care model development in conjunction with these partner organizations, all with the intent to provide patients with coordinated, seamless care transitions across care settings and, when appropriate, back to their home. There are several ways to achieve tightly aligned networks – organizations should be judicious when deciding if ownership over all components is the right strategy for them.

Reality: Physicians are critical to cultural and clinical transformation – this is an undeniable truth. However, not all physicians are well-educated about or in favor of clinical transformation to position them for success in population health. Some may be nearing the end of their careers, and this change may present a large burden. Placating to physician needs and preferences will not always bring about successful and unified change within an organization. Instead, try performance transparency. Initially, this may cause some discomfort among physicians; however, no physician wants to be the poorest performer, and this tactic may bring about the most rapid change in behavior. The enforcement of remedial action plans for physicians who do not follow established evidence-based protocols may also not be welcomed by all physicians, but will ultimately ensure that high-quality care is provided. While physician engagement is a critical element for success in population health management, it must be a mutual effort. Organizations that make the successful voyage to population health management need to weed out those vocally not on board, as well as those refusing to row in the same direction in their practices.

Myth #9:Patient satisfaction is the same as optimizing the patient experience.

Reality: Despite what physicians may think, patients aren’t really rating physicians on whether they “always communicated well with them” or “always controlled their pain well.” The truth is that patient satisfaction has many components. Ultimately, patients are rating physicians on factors such as whether they got better and had timely access, which can ignore critical aspects such as the cost and appropriateness of care being provided. One prominent study contended that patients who reported being most satisfied with their physicians had higher healthcare and prescription costs and were more likely to be hospitalized than less satisfied patients. Could physicians who have patient satisfaction scores tied to their compensation be less likely to advocate against unnecessary requested treatments or less likely to raise concerns about lifestyle and behavioral modification issues? Or could there be a correlation between high patient satisfaction scores and providers who actively tackle the hard-to-discuss issues the best? More research – and specifically innovative research – is necessary. Further complicating this issue is the new trend towards Yelp-style online public reviews influencing local perceptions of healthcare providers. As with any crowd-sourced review product, an issue arises when the public tends to only be inclined to offer their opinions when the service is exceptional, or the experience was considered an unpleasant one. Managing digital perceptions is yet another responsibility that consumer advancements and innovations have required of providers.

Myth #10:Patient satisfaction will increase if physicians spend more time with each patient.

Reality: Patient satisfaction is about much more than the length of an appointment. Ultimately, patients are concerned about receiving personal, high-quality care at the time they need it. A patient will be satisfied with their care if they feel they can access it when they need it; for example, when a patient is able to schedule an appointment on the day and at the time they wish to see their physician or other provider and if their wait time is minimal. Or, when a patient contacts their physician via a patient portal and receives a timely response. Furthermore, the patient wants to feel as though their physician is utilizing the appointment time to truly discuss their care, rather than reviewing old notes and labs and consistently typing on a computer; patients respond very positively to eye contact and listening skills as indicators that a physician is interested in a patient. A medical assistant or other office support staff can greatly assist physicians prepare for their appointments so that patients feel as though they are receiving the physician’s full attention, thereby bolstering the patient’s satisfaction with their visit.